The Bedpan: The poor can’t afford to follow public health advice

Why he matters: Britain’s most influential public health figure, Professor Marmot has spent the past 40 years researching health inequalities and the social determinants of health. In 2010 he undertook a strategic review of health inequalities for the government, producing the landmark study Fair Society, Healthy Lives.

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“As far as I’m concerned, it shouldn’t regress back to [the view that] health is a matter of individual responsibility.”

Sir Michael is explaining what he wants to see from the government’s impending green paper on prevention.

It must steer clear of the idea that “all we have to do is convey to people how to eat sensibly and then everything will be fine,” he says. “That would be a significant step backwards.”

“I’ll give you an example,” he adds, “If everyone followed Public Health England’s eating advice, people in the bottom decile of household income would spend 74 per cent of their income on food. So, there’s not much point telling them follow the healthy eating advice they can’t afford.

“We could have well-meaning ladies with nice accents saying ‘oh I can teach them to cook, you know… they just should eat more porridge’… But I don’t find that terribly reassuring,” he says.

Professor Marmot is not opposed to the idea that people should take personal responsibility for their health, in fact he said it is “vital”. “But we’ve got to create the conditions for people to be able to take responsibility.

“You can’t expect people to take responsibility for feeding their children healthy food if they’re in the bottom 10 per cent of household income and can’t afford to buy healthy food. Or… if they’re one of the million people who go off to food banks.”

“What I would like to see is an explicit recognition of [impact of] the social determinants of health.”

It is nine years since Professor Marmot released the strategic review, Fair Society, Healthy Lives – more commonly known as The Marmot Review.

Alan Johnson, then Labour health secretary, charged Professor Marmot with four tasks: to identify the evidence needed to underpin future policy and action; show how this evidence could be turned into practice; suggest targets and ways to measure progress; and publish a report that would help government develop a post-2010 health inequalities strategy.

However, improvements in life expectancy have slowed over the following 10 years, to the point where they have largely stopped and seem to be going backwards in some parts of the UK.

The country also seems to be seeing a rise in the so-called “deaths of despair”; including fatalities among middle-aged people from suicide, drug and alcohol overdoses, and alcohol-related liver disease.

These have been on the rise in the US for the past decade, while researchers in Glasgow have demonstrated its life expectancy is lower than in equally deprived Liverpool and Manchester because of alcohol and drug abuse.

“Our life expectancy problems initially were more due to mortality at older ages,” explains the professor. “But the most recent figures coming out of Public Health England suggested we’re now starting to see… a rise in mortality [from] deaths of despair.”

10 years on

Professor Marmot is producing a report for the Health Foundation marking 10 years since the Marmot Review was released. It will be published on the anniversary in February 2020 and provide evidence-based commentary on what has happened over the past decade to address health inequalities in the UK.

The first report initially had more impact than Professor Marmot thought it would. Commissioned by a Labour government and published three months before the 2010 general election, he was worried it was going to be cast off by an incoming Conservative administration.

“People said, ‘Oh, Marmot will go the way of Black’”, remembers the professor.

The Black Report, by Sir Douglas Black, was commissioned by a Labour secretary of state but Margaret Thatcher was in Downing Street by the time it was completed. When it was eventually published, it was derided in a foreword written by a government minister.

Patrick Jenkin, the secretary of state for social services, cut short any hope that the Black Review’s recommendations would lead to a major programme of public expenditure to address growing health inequalities.

Mr Jenkin wrote: “Additional expenditure on the scale which could result from the report’s recommendations… is quite unrealistic in present or any foreseeable economic circumstances, quite apart from any judgement that may be formed of the effectiveness of such expenditure.”

But after David Cameron walked into Downing Street in the summer of 2010, a white paper on public health did emerge.

Professor Marmot remembers that: “It said ‘we have to put reduction of health inequalities at the centre of our public health strategy’… and ‘we won’t solve this through the healthcare system alone’. ‘We need to take action on the social determinants of health’… I was pretty pleased with that.”

But the paper did not herald a bright new dawn. “The government priority was austerity. It was not implementing my review, it was cutting funding to local government, cutting funding to social care, quote ‘getting the welfare bill down’ unquote.

I’m not anti-government, [but I am] anti policies that will likely make health inequalities worse. And increasing child poverty, reducing the standard of living of people in the bottom deciles of the income distribution will make health inequalities worse.”

Talk is not cheap

Lately, the professor has detected a change for the better. He does not agree, therefore, that recent government statements on health inequalities and wider determinants are purely “lip service”.

“I think: ‘speech matters,’” he says. “Lip service implies ‘well they’re only talking, they’re not doing’. But I think talking means that the currency is changing; that it makes it legitimate to talk about social determinants of health.

“The fact that Theresa May, on the steps of Downing Street, talked about the burning injustice of health inequality was very encouraging.”

He baulks at the suggestion that, while health inequality and social determinants of health have entered mainstream political discourse, the UK has made little progress beyond raising the issue’s profile.

“No, that’s not true at all,” he says, claiming that several cities and local areas have taken up the six objectives identified in The Marmot Review as necessary to reduce health inequalities. These include ensuring children have the best start in life and that everyone has a healthy standard of living; the creation of health and sustainable places and communities; and strengthening the role of prevention.

“Coventry declared themselves a Marmot City, and they are now in the process of trying to get some indicators of whether that’s made any difference. A few weeks ago, we started work with Greater Manchester, because they said they’d like to take on these six domains as a basis for improving the [its populations] health and wellbeing.”

The devolved governments in Scotland and Wales have also made progress implementing research into childhood development and the impact of adverse childhood experiences, he says.

However, effectively tackling health inequity and addressing the social determinants of health will need cross government support in Whitehall, where there has been less traction. “I’m not complacent in any way” he says. “What I am saying, and this is my general approach is, I push on a door and if it’s closed I push on a different door and see where we can take up an action.”

Positive signs

Professor Marmot says he would like to see NHS doctors and other clinicians talking up the importance of tackling health inequalities.

“We’ve got to draw attention to the social determinants of health. Even though we in the medical profession can’t have influence on them directly, we can certainly advocate for changes on behalf of our patients.

“Child poverty is damaging children’s futures – we don’t have the levers to reduce child poverty, but it’s a health issue, we can stand up as doctors and nurses and other health professionals and say why we’re against child poverty.”

Professor Marmot is less comfortable discussing the degree to which the NHS long-term plan fits the bill for addressing health inequalities, saying he “can’t give you very informed judgement about that”. However, he says “I have no doubt at all that Simon Stevens and [NHS England chair] Lord Prior both understand what I’m talking about,” explaining they have both sought his expertise on the issue.

Next week: Tory commentator and Cameron biographer Danny Finklestein on Boris the PM

Coming up: NHS VAT campaigner Karin Smyth MP

If there is any political or influential figure you would like us to interview, please email alastair.mclellan@wilmingtonhealthcare.com or if you are reading this on the website leave them in the comments box.

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